The medical record is the basic legal document in medical malpractice
litigation. A poorly written, disorganized record is strong evidence of an
incompetent medical care provider. The poorly kept record is not, in itself,
proof of negligence on the part of the medical care provider, but it is proof of
substandard care. Conversely, medical personnel, constantly told that “the
good medical record is the best defense,” miss the point that the good medical
record is valuable only to the extent that it documents the actual rendering of
good medical care. A medical record can be legally disastrous if it
demonstrates the incompetence of the underlying medical care. Poor
documentation is actually an advantage to an incompetent defendant whose
best defense is obfuscation. A poor record may prevent the medical care
providers from establishing the good care they gave the patient, but a good
record is not a substitute for good care.